lung cancer the new staging system · 5th edition Тnm classification (lung cancer) -1997 6th...

LUNG CANCERthe new Staging

System

G.KIROVA

TOKUDA HOSPITAL SOFIA

STAGING SYSTEM

• Provides standardized nomenclature for exchanging information

• Groups patients according to the biologic behavior of their tumors

• Aids stratification of patients on the basis of different treatment strategies

• Enables evaluation of treatment strategies

• Defines patients prognosis

MAIN CHANGES7th Edition

9 new classifications

6 main changes

Мх elimination

Parallel anatomic and prognostic staging

Melanoma

GI carcinoma

GIST

Appendix carcinoma

Neuroendocrine tumors:

stomach, bowels, appendix,

lung

Intrahepatic

cholangiocarcinoma

Merkel cell carcinoma

Sarcoma uteri

Suprarenal cancer9ne

w c

lass

ific

atio

ns

6“b

ig”

Esophagus

Stomach

Lung

Skin

Cervix

Prostate

MAIN CHANGES7th Edition

Elimination of category Мх сМх could not exist (could not be proved)

рМх does not exist

рМ0 does not exist (except after autopsy)

сМ0 = clinically without metastasis; cM0 instead pM0 in case of

negative biopsy result from an existing lesion

сМ1 = clinically proved metastasis

рМ1 = pathologically proved metastasis (p.ex. cut biopsy)

MAIN CHANGES7th Edition

6“b

ig”

Esophagus

Stomach

Lung Skin

Cervix

Prostate

MAIN CHANGES7th Edition

TREATMENT POLICY

• Primary methods of lung cancer staging

– Clinical (non-invasive and minimally invasive)

– Pathological

• Clinical vs pathological staging (level of agreement 35% vs55%)

• Lung resection as the only curative treatment for lung cancer

• The goal of the preoperative evaluation is to not precludepatients from attempting surgical resection

• Pathological staging as a reference standard

Lopez-Encuentra et al; Comparison between clinical and pathological staging in 2994 cases of lung cancer; Ann Thor Surg 2005;79:974-979

Clifton F. Mountain

1924 - 2007

2nd, 3rd and 4th Editions of TNM classifiation (lung cancer) -1973 -1987

American Join Committee on Cancer

Union Internationale Contre le Cancer

2155 cases; MD Anderson Cancer Center; Texas

І stage

ІІ stage

ІІІ А stage

ІІІ Б stage

ІV stage

Т 1-2 N 0 М0

Т 1-2 N 1 М0

Т 1-3 N 2 М0

Т 3 N 0-1 M0

any Т N 3 M0

Т 4 any N М0

any Т any N М1

4th Edition ТNM classification (lung cancer) -1987

Tsuguo Naruke1934 – 2006

Naruke map Mountain-DresslerATS map

N1 N2

5th Edition ТNM classification (lung cancer) -1997

6th Edition TNM classification (lung cancer) - 2006

Stage

Occult carcinoma Tх N0 M0

Stage 0 Тis N0 M0

Stage І А T1 N0 M0

Stage І В T2 N0 M0

Stage ІІ А T1 N1 M0

Stage ІІ В T2 N1 M0

T3 N0 M0

Stage ІІІ А T1 N2 M0

T2 N2 M0

T3N1-2 M0

Stage ІІІ В any T N3 M0

Т4 any N M0

Stage ІV any Т any N M1

5319 pts

• 5319 pts North Am; 1975-1988

• Improvement in grouping of ptswith similar prognosis

• Limitations– Selected population of pts

– One geographic region

– No results validation

7th Edition ТNM

lung cancer – 2009

International Staging

Project on Lung Cancer

Peter Goldstraw

International Association for the

Study of Lung Cancer (IASLC)

The IASLC Lung Cancer DatabaseSummary of Cases Contributed to Project (1990 – 2000)

Total cases submitted 100,869

• Excluded from analyses 19,854

• Outside of 1990-2000 time frame 5,443

• Incomplete survival data 1,505

• Unknown histology 2,468

• Incomplete stage information 7,720

• Recurrent cases and other exclusions 1,603

• Carcinoids, sarcomas and other histologies 1,115

Included in analyses 81,015

•Small Cell Lung Cancer (and mixed SCLC/NSCLC) 13,290

•Non-Small Cell Lung Cancer 67,725

Updated from: Goldstraw P, Crowley JJ. The International Association for

the Study of Lung Cancer International staging project on lung cancer. J

Thorac Oncol 2006; 1: 281-286.

• 81495pts fulfilled the inclusion criteria

• 20 countries; Asia, Europe, N.America, Australia

• 45 different databases

Surgical

Series

Clinical

Trial

Surgical

Registry

0

5000

10000

15000

20000

0

2000

4000

6000

8000

10000

12000

Europe Australia N. America Asia

I

II

III

IV

The IASLC Lung Cancer Database

Clinical Stage Distribution by Continent, Non-small Cell Lung Cancer 53,646 Cases

Cancer Research and Biostatistics (CRAB)

Seattle, Washington, USA

• Internally validated by geographic regionand type of database

• Externally validated by being testedagainst the Surveillance, Epidemiology andEnd Results registries

Surgery

36%

Chemotherapy

21%

RT

11%

Surgery + Chemo

4%

Surgery + RT4%

Chemo + RT12%

Surgery + Chemo

+ RT 3%

WHAT’S NEW?

• NSCLC changes– T

• Size• Simultaneous nodule

– N• New LN map

– M• Malignant pleural

effusion

• SCLC staging strategy• Carcinoid tumors• New preoperative

functional assessment

T descriptors

Tumor sze- A 2cm cutpoint subdivides T1a and T1b- A 5cm cutpoint subdivides T2a and T2b

Rami-Porta R et; J Thor Oncol 2007;2:593-602

<2cm = T1a5y sv 77%

2-3cm = T1b5y sv 71%

3-5cm = T2a5y sv 58%

5-7cm = T2b5y sv 49%

>7cm = T35y sv 35%

T1a vs T1b(cut-point 2cm)

T2a vs T2b(cut-point 5cm)

T descriptorsSatelite nodules

The presence of an ipsilateralnodule in a different lobe isnow T4

The presence of satellite nodulesin the same lobe as the primarytumor is now T3

Previously: T4 Previously: M1

N descriptor

• No changes have been madein the N descriptor asdefined in the previous TNMstaging system

• IASLC International StagingCommittee has developed anew node map:

- UPPER ZONE: stations 1 to 4

- AORTOPULMONARY ZONE: stations 5 and 6

- SUBCARINAL ZONE: station 7

- LOWER ZONE: stations 8 and 9

- HILAR ZONE: stations 10 and 11

- PERIPHERAL ZONE: stations 12 to 14

• Survival analysis by the number of involved nodal zones:– Single N1 (48%)– Multiple N1 or single N2 (35%/34%)– Multiple N2 (20%)

Multilevel N2 disease not recommended for primary surgical resection

Sakao Ann Thor Surg 2006

M descriptors

The M descriptor defines the extent of spread to distantsites:

• Mo: No distant metastasis• M1a: Separate tumor nodules in a contralateral lobe or tumor with

pleural nodules or malignant pleural dissemination.• M1b: Distant metastasis

M1a nodule in contralateral lung

Previously: T4

Previously: T4

M1a pleural metastases

M1b distant (extrathoracic) metastases

Previously: M

NB!Paraneoplastic syndrome is not accepted as a metastatic process and is not a contraindication for surgical treatment

- 1950 Veterans Administration Lung Study Group (VALSG)- 1989 IASLC- 2010 IASLC/UICC, 7th edition

histology at initial presentation; adequate staging information atbaseline; adequate follow-up12620 cases

SCLC

VI vs VII Edition

CO-MORBIDITIES

• PE

• Cardiac diseases

• Lung diseases– Emphysema

– COOPD

• Second primary tumor

A Charloux et al; Lung function evaluation before surgery in lung cancer patients: how are recent advances put into practice? A survey among members of the European Society of Thoracic Surgeons (ESTS) and of the Thoracic Oncology Section of the European Respiratory Society (ERS)

• preliminary cardiologic screening

• systematic measurement of the diffusing capacity for carbon monoxide (DLCO)

Decreased performance status was associated with an increased mortality and was shown to be an independent significant factor in determining survival

Conclusions

• The revised staging system – Is more accurately correlated with survival when

compared with the prior staging system

– Is more closely reflected trends in both definitive and paliative treatment

The Future

“Follow up” of the present data basis

8th Edition 2016

Prospective analysis (prognostic information based on the tu

biology and tu genetics; implication of imaging)

9th Edition 2023

All treatment decisions in oncology practice are based on the available

prognostic data